Venous Excess Ultrasound for Personalized Resuscitation in Septic Shock

Phase 3Not Yet RecruitingNCT06696391

Western University, Canada80 enrolled

Overview

The goal of this pilot clinical trial is to determine if conducting a larger study using venous excess ultrasound (VEXUS) to guide fluid management in patients with septic shock is feasible. Septic shock is a life-threatening condition where infection causes dangerously low blood pressure. While fluids are essential for treatment, too much fluid can harm the kidneys and result in the need for dialysis. The main questions it aims to answer are: 1. Is it feasible to recruit patients, obtain consent, and follow the VEXUS-guided management protocol? 2. Does VEXUS-guided management, compared with usual care, improve the health and well-being of patients with septic shock? Researchers will compare two groups: one receiving VEXUS-guided fluid management versus another receiving standard care, to assess the feasibility of a larger trial and explore whether VEXUS prevents fluid overload and kidney problems. Participants in the VEXUS group will: 1. Undergo VEXUS scans every 24 hours for 3 days 2. Receive fluid management guided by VEXUS findings (including fluid restriction or removal if we identify venous congestion) and undergo cardiac ultrasound if we identify moderate to severe congestion 3. Be monitored for 28 days to track kidney function, need for dialysis, and survival.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

NONE

Enrollment

Conditions

Septic Shock Sepsis

Interventions

Venous Excess Ultrasound (VEXUS)-Guided ManagementOTHER

Expert operators will perform VEXUS within 6 hours of randomization and repeat the assessment every 24 hours for 3 days, or until ICU discharge or death. After each assessment, investigators will grade the severity of venous congestion using a modified version of the VEXUS score and provide updated management recommendations. Patients without congestion will receive standard fluid management. For mild congestion, investigators will implement fluid restriction (e.g., minimizing maintenance fluids) while maintaining nutrition and blood product administration as clinically indicated. For moderate to severe congestion, investigators will 1. target negative fluid balance (-1 to -2L/24h) through fluid restriction and diuretics, 2. perform cardiac ultrasound to guide inotrope administration and optimize RV physiology, and 3. optimize PEEP for ventilated patients. All patients will receive the standard of care based on Surviving Sepsis Campaign guidelines.

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. Adult patients (≥18 years) 2. Within 12 hours of meeting septic shock diagnosis based on following Sepsis-3 criteria: requirement for vasopressors to maintain organ perfusion, lactate \> 2 mmol/L, and suspected or confirmed infection) 3. Within 48 hours of intensive care unit admission. Exclusion Criteria: 1. Already receiving renal replacement therapy 2. Patients for whom a decision to initiate renal replacement therapy has been made prior to study enrolment 3. Patients who have limitations on medical therapy or restrictions on goals of care 4. Active bleeding causing hemodynamic instability 5. Veno-venous or veno-arterial extracorporeal membrane oxygenation 6. Previously enrolment in study 7. 10% or more of body surface area acute burn injury 8. Suspected or confirmed liver cirrhosis 9. Established allergy to sulfa drugs; 10. Patients receiving treatments that require continuous IV fluid infusions (e.g., diabetic ketoacidosis, diabetes insipidus) 11. Unable to measure fluid balance accurately 12. Contra-indication to study recommended interventions (e.g., diuretics, inotropes) 13. Unable to perform VEXUS due to anatomical barriers (e.g., surgical dressings); 14. Unable to complete VEXUS scan during the 6-hour resuscitation window 15. Moderate to Severe Tricuspid Regurgitation 16. Untreated Metabolic/biochemical findings (Hypokalemia \[K+\]\< 3.0 mmol/L; metabolic alkalosis \[Bicarbonate \> 40 mmol/L and/or pH \> 7.55\], Hypomagnesemia \[Mg2+\] \< 0.6, and Hypernatremia \[Na+\] \> 155 mmol/L)

Outcomes

Primary Outcomes

Recruitment Rate

Number of participants enrolled during the recruitment period who successfully complete study procedures and follow-up.

Time frame: Up to 160 weeks

Secondary Outcomes

Consent rate

The total number of eligible participants consented divided by the total number of eligible participants approached for consent.

Time frame: From enrollment to the end of the study period at 28 days

VEXUS scan completion rate

The number of participants who successfully undergo a VEXUS scan and, if applicable, cardiac evaluation, divided by the total number of participants randomized to the intervention arm.

Time frame: From enrollment to the end of treatment period at 3 days

Protocol Adherence

Intervention arm: For fluid balance adherence, we will calculate the proportion of participants who achieved the protocol-specified fluid balance targets on days 1 to 3, divided by the total number of participants in the intervention arm. This metric will account for participants who withdraw or deviate from the protocol. To assess adherence to inotrope initiation based on POCUS findings, we will determine the percentage of participants who received inotropes when indicated by POCUS results, as per protocol guidelines, divided by the total number of participants with POCUS findings warranting inotrope initiation. Control arm: The number of participants in the control arm who do NOT receive a VEXUS scan during the 28-day study period (or until ICU discharge or death) divided by the total number randomized to this arm.